Improvement Stories

Promoting Comfort in Labor: Nurses Implement Use of Acupressure

Contributor:Sharon Dalrymple RN, BN, MEd, LCCE, FACCEClinical Nurse EducatorHigh River Hospital Community Maternity Program CNECommunity Maternity Unit, High River Hospital, High River Alberta

What did you set out to change or improve?A few of the Nurses (RNs) on our unit at High River Maternity Program wanted to enhance our resources for labor comfort techniques. We do 1:1 nursing care for women in active labor and RNs here do a wide range of massage, breathing, hydrotherapy, emotional support and relaxation techniques for their families in labor. Acupressure seemed to be a natural extension of those labor support skills for us.

How did you change it? What new process or practice did you put in place?We found a workshop in 2010, facilitated by Debra Betts, RN, from New Zealand, who has worked with acupressure in labor for over 20 years. Three RNs and the Clinical Nurse Educator (CNE) attended the workshop. The workshop covered a wide range of acupressure points of use in pregnancy, early labor, active labor, second stage, third stage and even postpartum.

The CNE and one RN then conducted a literature search (medical and non-medical) about the concept of acupressure and Chinese medicine and pressure points for acupuncture too. Randomized Control Trials and other levels of evaluation were also reviewed. Surprisingly, there is a large body of research related to nausea in the post-op phase, and related to cancer treatment side effects, but not a great deal for childbearing.

From there a core group of three workshop attendees designed a plan for using acupressure in labor as a pilot project. Acupressure was presented to the clients and other team members as a form of massage. Just like any other form of comfort technique, the RN would ask if she could try the technique and see if the laboring woman found it helpful or not. We put this in the same context as massage and many other comfort techniques in that it cannot hurt, and it is intended to help. If it was not perceived as helpful to the woman, then we would switch to some other kind of comfort measure.

From the evening after the workshop and over the next six months we gathered feedback and experiences from the four of us and our clients on acupressure points used in labor. From there, we felt like acupressure could be used in our facility as a viable technique.

The next step was to share our experiences and materials with our facility nursing staff. We conducted inservices, the CNE included acupressure in orientation of new staff, and it was introduced to the Low Risk Clinic physicians and midwives. The same approach was used related to acupressure as in the pilot phase: it is intended to enhance comfort and efficient labor, it is like any other form of comfort measure, and if the woman perceives that it is helpful, we will continue to do it; if not, then we switch to something else.

With more people involved, our scope of practice using the acupressure techniques expanded to:

use in pregnancy (specifically to induction after 37 weeks gestation),

Over time we collected more helpful stories and experiences across the wide scope of childbirth. As more nursing staff used the techniques and found positive results, the more the RNs were motivated to use this modality.

Physicians from the Low Risk Clinic also saw the use of acupressure across the childbearing scope, and many realized that it was a helpful tool for pain management and efficient labor. They soon were requesting that acupressure be taught to the patients, especially for 37 week plus gestation for induction. At least one LRC physician has used acupressure in her own labor.

Who was involved in making the change and what was each person’s role?

This is an example of how four nurses used their enthusiasm and influence to change and augment a comfort technique practice to the larger practice team of nearly 60 people. The women themselves and their partners have also helped to make the change happen, as they share their stories of comfort and labor progress with their social circles.

How did you determine if the change worked?Our main indicator is that the use of acupressure for the scope of pregnancy, labor, birth and postpartum is widely used and supported across all members of our multiprofessional team.

How do we define success?Success is defined as women and their families and team members perceiving that there is value in using the techniques. This has happened in almost all of the times of use. Acupressure has become one of the standard comfort techniques in our practice over time. We have even been able to show that in some cases (eg: retained placenta, cervical lip, increasing urge to push) that acupressure seemed to be the trigger needed and avoided additional intervention.

Sharing our stories and techniques of acupressure has also been positively accepted. From the original core group of four RNs, we have done presentations to: perinatal education groups, doulas, midwives, labor and delivery staff, and concurrent session attendees (RNs and physicians) in a variety of settings.

How did you ensure your change did not have any unintended negative consequences?The literature search helped reassure us that there are positive intentions with the use of acupressure with a goal to balancing the body’s energy pathways. The book and research that our original facilitator Debra Betts shared with us was also reassuring. In addition, we also consulted and continue to work closely with a local acupuncturist who has studied this field extensively in her career. She is an excellent resource for us.

What was the biggest barrier to making the change?Lack of evidence-based research on acupressure was certainly an initial barrier.

Skepticism was and still is the biggest barrier. A few physicians and some doulas are skeptical about the technique of acupressure. The doula groups have been cautioned that this technique may need to be a certifying skill for them.

How did you overcome that barrier?Overall, the reception has been positive, and especially when it is introduced in the context of “cannot hurt, may help”, like other massage techniques. The proof is in the results and outcomes, and that has been positive enough for care providers and patients to be willing to try it.

If you had one piece of advice for someone who wanted to make a similar change, what would it be? Be realistic about the use of acupressure– from an evidence/research point of view, and from a perception point of view– it may help, let’s try it.